Polyethylene glycol versus lactulose in the treatment of hepatic encephalopathy: a systematic review and meta-analysis

Abstract

BackgroundHepatic encephalopathy (HE) is defined as brain dysfunction that occurs because of acute liver failure or liver cirrhosis and is associated with significant morbidity and mortality. Lactulose is the standard of care till this date; however, polyethylene glycol (PEG) has gained the attention of multiple investigators.MethodsWe screened five databases namely PubMed, Scopus, Web of Science, Cochrane Library and Embase from inception to 10 February 2021. Dichotomous and continuous data were analysed using the Mantel-Haenszel and inverse variance methods, respectively, which yielded a meta-analysis comparing PEG versus lactulose in the treatment of HE.ResultsFour trials with 229 patients were included. Compared with lactulose, the pooled effect size demonstrated a significantly lower average HE Scoring Algorithm (HESA) Score at 24 hours (Mean difference (MD)=−0.68, 95% CI (−1.05 to –0.31), p<0.001), a higher proportion of patients with reduction of HESA Score by ≥1 grade at 24 hours (risk ratio (RR)=1.40, 95% CI (1.17 to 1.67), p<0.001), a higher proportion of patients with a HESA Score of grade 0 at 24 hours (RR=4.33, 95% CI (2.27 to 8.28), p<0.0010) and a shorter time to resolution of HE group (MD=−1.45, 95% CI (−1.72 to –1.18), p<0.001) in favour of patients treated with PEG.ConclusionPEG leads to a higher drop in the HESA Score and thus leads to a faster resolution of HE compared with lactulose.

Comparison of polyethylene glycol 3350 electrolyte solution and lactulose in patients with overt hepatic encephalopathy: A retrospective study from a tertiary care hospital

“…Reason for this difference is that alcohol consumption is almost negligible in our society. Improvement in grade of encephalopathy in 24 hours after treatment with PEG was seen in our study and this was consistent with Hoila et al [25]. [28] in which hospital stay was 4±1 days of hospitalisation in PEG group versus 8±2 days of hospitalisation in lactulose group.…”

“…Attar A. et al demonstrates that PEG electrolyte solution is more powerful laxative than lactulose [24]. Our study demonstrates that PEG 3350 electrolyte solution is more effective than lactulose in improvement of hepatic encephalopathy with mean drop in HESA score by 1.37 in PEG group as compared to only 0.65 drop in lactulose group at 24 hours of treatment, the results being consistent with the study conducted by Hoila et al [25].…”

“…The difference in etiology for liver disease in our study group compared to Hoila et. al [25] was that alcohol was the most common etiological agent for liver cirrhosis found in the meta-analysis compared to 2.5 % of alcoholic etiology for liver cirrhosis in our study.…”

Lack of Access to Rifaximin Upon Hospital Discharge Is Frequent and Results in Increased Hospitalizations for Hepatic Encephalopathy

“…Recent results published in a systematic review and meta-analysis demonstrated higher drops in the HE Scoring Algorithm (HESA) score and thus faster resolution of HE when compared with lactulose alone. 21 Neomycin and metronidazole are mentioned in the American Association for the Study of Liver Diseases/European Association for the Study of the Liver (AASLD/EASL) practice guidelines as alternative agents, but, based on unfavorable safety profiles, are not routinely recommended. 6,22 Vancomycin has fallen out of favor and is no longer recommended as a treatment option due to limited studies, high cost, and increased prevalence of drug resistance associated with its use.…”

New Therapies of Liver Diseases: Hepatic Encephalopathy

“…Therefore, PEG applicability may be limited to patients in whom naso-gastric tube placement is safe and successful. A recent review and meta-analysis of four studies [20] showed that a single dose of PEG significantly improved clinical features of HE after 24 h and reduced the number of days for HE resolution compared to lactulose; however, no differences were observed in hospitalization length.…”